Navigating Post-Intervention Management in Coronary Artery Disease

In the dynamic landscape of coronary artery disease management, post-intervention care defines the future of cardiac health. As physicians navigate the complexities of preventing thrombotic events after stenting, balancing the efficacy and safety of antiplatelet therapies becomes paramount.

Antiplatelet therapy remains a cornerstone in post-stenting care, with recent insights from the reported ACS post-PCI trial indicating that de-escalation to P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) was noninferior for ischemic outcomes and reduced bleeding.

In this strategy, reduced bleeding stems from de-escalation—stopping aspirin after a short DAPT course while continuing a P2Y12 inhibitor—maintaining antiplatelet efficacy with fewer hemorrhagic events than prolonged DAPT.

DAPT has long stood as the standard, yet evolving research supports tailored approaches: in selected patients—particularly those at high bleeding risk—early discontinuation of aspirin after 1–3 months of DAPT, while maintaining a P2Y12 inhibitor, can mitigate bleeding without clearly compromising ischemic protection; ACS populations require careful risk stratification.

Beta-blockers present their own narrative: they are recommended in the acute post–myocardial infarction period and for patients with reduced left ventricular ejection fraction or other clear indications, whereas routine long-term use in those with preserved ejection fraction after an uncomplicated MI is not universally endorsed.

In patients with reduced ejection fraction or established HFrEF after MI, their use is associated with lower mortality and slower heart failure progression.

For heart failure management, sacubitril/valsartan is indicated for chronic symptomatic HFrEF to reduce morbidity and mortality, typically alongside guideline-directed therapies such as beta-blockers; routine early initiation immediately post-MI without established HFrEF is not supported by mixed evidence, as large trials have not demonstrated clear superiority over ACE inhibitors in that setting.

Together, these data signal a move toward more tailored, patient-centered care rather than a wholesale paradigm shift.

The next logical step involves integrating these evidence-based therapies into practice to optimize post-intervention outcomes. Clinicians must remain vigilant, adapting to new evidence that informs best practices, and apply rigorous risk stratification—de-escalating DAPT selectively and prioritizing beta-blockers and ARNI therapy for patients with reduced ejection fraction or established HFrEF.

Key Takeaways:

• Optimizing antiplatelet therapy post-stenting involves careful consideration of both DAPT and monotherapy options to reduce bleeding and ischemic events.
• Beta-blockers are essential in the acute post-MI period and for patients with reduced ejection fraction or other clear indications; routine long-term use for all is not universal.
• Sacubitril/valsartan is superior to enalapril in chronic symptomatic HFrEF and may be considered in appropriate patients; routine early post-MI use without established HFrEF is not established.